Appeals and Grievance RN 100% Remote for CA residents id-15293

January 18, 2025

Overview:

Our client, a mutual benefit corporation and health plan provider, seeks an accomplished Appeals and Grievance RN.

*** Candidate must be authorized to work in USA without requiring sponsorship ***

***************************************************************

*** Location: Long Beach, CA (100% Remote acceptable)

*** Duration: 6 months contract w/ possibility of extension or conversion to FTE role

Notes:

100% remote role.
Work hours: 08:30am - 05:00pm PT.

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Description:

The Commercial Appeals and Grievance RN reviews and processes appeals resulting from a member generated pre-service or post-service concern or complaint.
The Commercial Appeals and Grievance RN will report directly to the Nurse Manager and be responsible for reviewing all medical records and documentation concurrently while processing these member-generated appeals.
In this role, the RN will perform accurate and timely first level reviews according to company and regulatory standards, utilize National Coverage Determination (NCD) guidelines, Local Coverage Determination (LCD) guidelines, Milliman Care guidelines and other nationally recognized sources such as NCCN and ACOG.
The Appeals and Grievance RN will review appeals for benefits, medical necessity, coding accuracy and medical policy compliance.
In this role the Appeals and Grievance RN will collaborate with medical directors, coordinators, and leadership to review, process, and provide a final determination for all clinical appeals with clear rationales and any follow up actions necessary to ensure our members are provided with quality access to provider care.

Qualifications:

Bachelor of Science in Nursing (BSN) required.
Registered Nurse (RN) of California required.
Must have 5 years experience.
Managed Care experience (MCG, LCD and NCD knowledge) – 2 years minimum.
Acute or Sub-Acute Clinical experience – 2 years minimum.
Knowledge of Commercial and Medicare Health Coverage Benefits and Reviews.
Previous experience with prior authorization, pre-service and post-service review.
Software skills required: Excel, Microsoft, PDF, Shared-Drive, MS Teams, SharePoint.

Nice to haves:

Strong understanding of regulatory requirements pertaining to health insurance (NCQA, CMS, DMHC, DHCS).
Strong skills with Excel, Microsoft, PDF, shared drive, medical records review.
Ability to work in a fast paced and changing environment.
Strong communication skills.
Ability to work independent and in a team setting.
Strong clinical assessment skills and ability to recognize discrepancies or inaccuracies in medical determinations/clinical documentation.

I'd love to talk to you if you think this position is right up your alley, and assure a prompt communication, whichever direction. If you're looking for rewarding employment and a company that puts its employees first, we'd like to work with you.

Satwinder “Sat” Singh

Lead Technical Recruiter

Company Overview:

Amerit Consulting is an extremely fast-growing staffing and consulting firm. Amerit Consulting was founded in 2002 to provide consulting, temporary staffing, direct hire, and payrolling services to Fortune 500 companies nationally, as well as small to mid-sized organizations on a local & regional level. Currently, Amerit has over 2,000 employees in 47 states. We develop and implement solutions that help our clients operate more efficiently, deliver greater customer satisfaction, and see a positive impact on their bottom line. We create value by bringing together the right people to achieve results. Our clients and employees say they choose to work with Amerit because of how we work with them - with service that exceeds their expectations and a personal commitment to their success. Our deep expertise in human capital management has fueled our expansion into direct hire placements, temporary staffing, contract placements, and additional staffing and consulting services that propel our clients’ businesses forward.

Amerit Consulting provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state, or local laws.

This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation, and training.

Applicants, with criminal histories, are considered in a manner that is consistent with local, state, and federal laws.

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Common Interview Questions And Answers

1. HOW DO YOU PLAN YOUR DAY?

This is what this question poses: When do you focus and start working seriously? What are the hours you work optimally? Are you a night owl? A morning bird? Remote teams can be made up of people working on different shifts and around the world, so you won't necessarily be stuck in the 9-5 schedule if it's not for you...

2. HOW DO YOU USE THE DIFFERENT COMMUNICATION TOOLS IN DIFFERENT SITUATIONS?

When you're working on a remote team, there's no way to chat in the hallway between meetings or catch up on the latest project during an office carpool. Therefore, virtual communication will be absolutely essential to get your work done...

3. WHAT IS "WORKING REMOTE" REALLY FOR YOU?

Many people want to work remotely because of the flexibility it allows. You can work anywhere and at any time of the day...

4. WHAT DO YOU NEED IN YOUR PHYSICAL WORKSPACE TO SUCCEED IN YOUR WORK?

With this question, companies are looking to see what equipment they may need to provide you with and to verify how aware you are of what remote working could mean for you physically and logistically...

5. HOW DO YOU PROCESS INFORMATION?

Several years ago, I was working in a team to plan a big event. My supervisor made us all work as a team before the big day. One of our activities has been to find out how each of us processes information...

6. HOW DO YOU MANAGE THE CALENDAR AND THE PROGRAM? WHICH APPLICATIONS / SYSTEM DO YOU USE?

Or you may receive even more specific questions, such as: What's on your calendar? Do you plan blocks of time to do certain types of work? Do you have an open calendar that everyone can see?...

7. HOW DO YOU ORGANIZE FILES, LINKS, AND TABS ON YOUR COMPUTER?

Just like your schedule, how you track files and other information is very important. After all, everything is digital!...

8. HOW TO PRIORITIZE WORK?

The day I watched Marie Forleo's film separating the important from the urgent, my life changed. Not all remote jobs start fast, but most of them are...

9. HOW DO YOU PREPARE FOR A MEETING AND PREPARE A MEETING? WHAT DO YOU SEE HAPPENING DURING THE MEETING?

Just as communication is essential when working remotely, so is organization. Because you won't have those opportunities in the elevator or a casual conversation in the lunchroom, you should take advantage of the little time you have in a video or phone conference...

10. HOW DO YOU USE TECHNOLOGY ON A DAILY BASIS, IN YOUR WORK AND FOR YOUR PLEASURE?

This is a great question because it shows your comfort level with technology, which is very important for a remote worker because you will be working with technology over time...

DISCLAIMER

Other Jobs You May Be Interested In

Other Jobs You May Be Interested In

Common Interview Questions And Answers

1. HOW DO YOU PLAN YOUR DAY?

2. HOW DO YOU USE THE DIFFERENT COMMUNICATION TOOLS IN DIFFERENT SITUATIONS?

3. WHAT IS "WORKING REMOTE" REALLY FOR YOU?

4. WHAT DO YOU NEED IN YOUR PHYSICAL WORKSPACE TO SUCCEED IN YOUR WORK?

5. HOW DO YOU PROCESS INFORMATION?

6. HOW DO YOU MANAGE THE CALENDAR AND THE PROGRAM? WHICH APPLICATIONS / SYSTEM DO YOU USE?

7. HOW DO YOU ORGANIZE FILES, LINKS, AND TABS ON YOUR COMPUTER?

8. HOW TO PRIORITIZE WORK?

9. HOW DO YOU PREPARE FOR A MEETING AND PREPARE A MEETING? WHAT DO YOU SEE HAPPENING DURING THE MEETING?

10. HOW DO YOU USE TECHNOLOGY ON A DAILY BASIS, IN YOUR WORK AND FOR YOUR PLEASURE?

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